BACKGROUND

Alarming racial and ethnic disparities have been reported regarding risk of Covid-19 infection, access to testing, and adverse outcomes. Nevertheless, as of mid-April, many states were not reporting Covid-19 mortality by race and ethnicity. 1 Among states that are reporting race/ethnicity data, the completeness of the data and the magnitude of population-mortality disparities remain unclear. Furthermore, the profound differences in population age distribution across racial and ethnic groups are infrequently incorporated into analyses, potentially leading to substantial underestimates of disparities. We therefore evaluated the completeness of race and ethnicity reporting in Covid-19 mortality data across states, and estimated age-adjusted disparities in population mortality rates.

METHODS

We conducted a cross-sectional study using publicly reported Covid-19 mortality data available on state websites 1, 2 as of April 21, 2020. We focused on Black, Latinx, and White populations as they are the largest groups represented in these data. We used indirect standardization to assess the population mortality rate across racial/ethnic groups, accounting for the younger age distributions of the Latinx and Black populations. 3, 4 First, we determined the relative risk (RR) of Covid-19 death at the national level across age groups (< 45, 45–54, 55–64, 65–74, and 75+ years old), based on CDC data. 5 Because mortality data were not available for each age/race/ethnic group by state, we applied these age-related RRs to the observed mortality rates for the White population for each state. We then applied indirect adjustment, calculating the number of expected deaths if the Latinx and Black groups had the same age-specific mortality rates as the White population and compared that with the observed death counts, estimating the standardized mortality ratio (SMR) and 95% confidence interval (95% CI) for each state. In this random effects meta-analysis, we estimated the pooled effect of race/ethnicity on population-level mortality (ie, Black vs White) across states using inverse variance weighting. 6

RESULTS

We found that 28 states, and NYC, reported race-and ethnicity-stratified Covid-19 mortality. There was substantial variation in the percent with missing race/ethnicity data, with only eight states missing such data on< 5% of decedents (Fig. 1). There was substantial variation in the association between Black race and mortality across states (Fig. 2a). In 22 states (plus NYC), the risk of Covid-19-associated death was significantly higher for the Black than the White population, ranging as high as 18-fold higher in Wisconsin. When aggregating the data from all states (and NYC), the RR of death for Black vs White population was 3.57 (95% CI: 2.84–4.48). Findings were similar for the Latinx population, which experienced an 88% higher risk of death than White patients (RR for Latinx vs White: 1.88: 1.61–2.19). Unadjusted summary ratios were lower than the adjusted estimates indicated above in both patient groups (RR for Black vs White: 1.96: 1.47–2.62; RR for Latinx vs White: 0.66: 0.53–0.83). In 12 states, as well as NYC, Latinx people had a significantly higher risk of Covid-19-related mortality than White people (Fig. 2b). There were no states in which the Latinx population had a significantly lower mortality.